Why (Good) Documentation Is So Important

Let’s imagine you’re watching a re-run of Law and Order, and you’re following along with how the investigation and proceedings take place. The key that makes or breaks each case is… you guessed it – evidence. The quality and quantity of the evidence, how well the story fits the evidence, and where the evidence leads paints a strong picture of what may or may not have happened. As you might already know, if the evidence is missing, weak, inconclusive, or put together in ways that doesn’t make sense, it doesn’t exactly bode well for the prosecution.

This analogy leads me into the concept of clinical documentation. For whatever reason, documentation standards have seemed to border on the appalling to mediocre over the decades, and they’re really only put into the public eye in cases of malpractice (even then, it is questionable how much the public really learns). Generally, documentation is handled by poorly staffed, underpaid, and overwhelmed practitioners who struggle to keep up with the current caseload, much less the backlog of what has already transpired. Then exists the transcription of the content in the charts. I can only imagine the difficulties of coders before the rise of computers when deciphering paper records. It was more than a difficult task to identify if correct diagnoses and comorbid conditions were being legibly documented. As a result, coders have tended to ‘under-code’ and bill less than appropriate, for fears of audits undermining the hard work they do.

The time for change is now.

I note with irony that ICD-10 (that is, the International Classification of Diseases) has been used by World Health Organization member states since 1994, and yet we are now mere months away from implementing it ourselves in the United States. Yes, it only took twenty years, but well, better late than never. I want to take the time to point out a key sentence that are present in the guidelines developed by four organizations who should know what they are doing (American Hospital Association, Centers for Medicare and Medicaid Services, American Health Information Management Association, and National Center for Health Statistics): “The importance of consistent, complete documentation in the medical record cannot be overemphasized.”

This is a bit of an understatement. Entire claims have been denied for expensive patient stays (and yes, it is expensive) because of poor and shoddy clinical documentation. Now, keep in mind that even these claim denials are probably only scratching the surface of how poor documentation standards can be – not too many billers, coders, or legal professionals have the time to read thousands of pages of documents every single day to get the story. The bigger question really is: why should they?

Like an effective court case, whether it is for the defense or prosecution, clear, succinct, and precise streams of evidence (meaning, documentation) provides a good and convincing story of why the hospital needs to be paid an ‘x’ amount of money for its services. If it is lazily put together (relying on medical students) or worse, illegible, rife with spelling errors, meaningless copying and pasting, and unnecessary delays in signing charts, it renders that clinician’s judgment almost meaningless, and in the process, negatively impacts the revenue cycle and invalidates the hard work of everyone who took on the care of a critically ill patient.

As the burden towards price transparency and consumer awareness increases, the doctors, hospitals, and systems who can actually plan ahead will be the ones who reap the benefits… and really, the standards are not unreasonable for a thinking person to achieve. Better documentation practices benefit everyone: better and more accurate delivery of healthcare, improvements in quality indicators, healthcare planning, reimbursement, and research. Everyone is happy – doctors, nurses, coders, providers, insurers, regulatory agencies, and researchers.

Most of all, the patient is happy (relatively speaking); these patients could be your mother, your child, your friend, and even yourself. We will all be patients one day, in some shape or form – wouldn’t we want a standard that could be easily achieved with the technologies of today?

Personally, my goal for healthcare delivery is to achieve a six-sigma level, comparable to that of manufacturing and airline industries, where a particular process has no more than 3.4 defects (that is, mistakes) per million occurrences. That level of quality may be hard to achieve, but in an industry full of similar-minded perfectionists with more than sufficient technological advances at our fingertips, why is this so difficult?

Daniel L. W. Hanley, MD, MS, CDIP's picture

Daniel L. W. Hanley, MD, MS, CDIP

Contributor

Daniel L. W. Hanley, MD is a physician specializing in family medicine with subject matter expertise in electronic medical records, clinical documentation improvement, education within diverse groups of people, and medical research. His passion for business, science and technology, and writing for broad audiences supports his goal of becoming the ultimate medical communicator. Hanley received his BS in Business Administration and Biology from The College of New Jersey and his MD from Loyola University of Chicago. He also holds a master's degree in Biotechnology from The Johns Hopkins University.

 

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